Patient Portal

Parental Access to the Online Medical Record of a Child Under 14 Years Old

After completing this form, hit the 'Continue' button and you will be prompted to print the form to be submitted. Sign in the designated area and then mail or fax it to the address listed on the printed form. If you do not have printing capabilities, please do not proceed.

Requestor (Birth/Adoptive Parent or Legal Guardian) Information

Note: Access to a child´s online record is only available to birth/adoptive parents or legal guardians. If you are not an existing patient, a medical record number will be created for you. To minimize duplicate records, please provide any former names you may have used previously.

Please indicate your relationship to the child by selecting one of the following:*

Important Notice for Adoptive Parents: If the child is adopted, please contact Health Information Management at phone number 570-271-6116 to verify that clinical information for your child is made available to the treatment team.

Requestor Name:*Requestor Address Same as Child?Street:*City:*State:*

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Dist of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Zip:*

Requestor Medical Record Organization:

Select...

Geisinger

CommunityCare

Susquehanna Valley Medical Specialties

Requestor Medical Record #: Requestor Date of Birth:* Email (to receive notification when a new message is posted to your child´s MyChart (Powered by Geisinger) record):* All Former Name(s) - e.g. Former Married or Maiden Name:

Do you (parent/legal guardian) have an active MyChart (Powered by Geisinger) account?
Yes
No
Unsure

Is this request to access the patient's MyChart Bedside information while the child is admitted to the hospital?*
Yes
No